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The British Journal of Psychiatry (2012)

200, 439441. doi: 10.1192/bjp.bp.112.110742

Editorial

Psychodynamic psychiatrys green shoots


Jeremy Holmes

Summary Declaration of interest


Psychodynamic psychiatry makes a significant educational, J.H. was Chair of the Faculty of Psychotherapy at the Royal
scientific and therapeutic contribution to contemporary College of Psychiatrists 19982002.
psychiatry. Recent developments in geneenvironment
interaction, neuropsychoanalysis and the accumulating
evidence base for psychoanalytic therapies and their
implications for practice are reviewed.

health effects in adversity, but positive effects under conditions


Jeremy Holmes is Visiting Professor at the University of Exeter. His latest of sensitivity and support, the latter including the kinds of
book, Exploring in Security: Towards an Attachment-Informed Psychodynamic
Psychotherapy, was awarded the 2010 Goethe Award. health-promoting relationships inherent in psychodynamic
therapies. Second, implicit in this model is the need for measures
of the relational environment equal in sophistication to those of
Within the broad church that is psychiatry, psychodynamic modern genomics. Psychodynamic psychiatry provides just such
approaches have until recently played a significant role. Under- a science of intimacy. An example is the Adult Attachment
standing the developmental dynamics and defences which underlie Interview,3 which, in contrast to crude pen-and-paper checklists,
symptoms, sensitivity to transference and countertransference as taps into a persons perception of their relational environment,
manifest in the therapeutic setting, and skilfulness in handling both current and developmental, and can be used to track changes
the psychodynamics of the doctorpatient relationship, even when in the inner world in the course of psychotherapy.
the focus is primarily psychopharmacological, are basic aspects of
psychiatric expertise integral to training and practice.
Neuropsychoanalysis
Despite this history, and being viewed by service users as an
essential component of mental healthcare, psychodynamic
A second growth point for psychodynamic psychiatry is in the
psychiatry has become something of an endangered species. Can
new-minted niche of neuropsychoanalysis, which has captured
it survive as a significant force within psychiatry or is it doomed
the imagination of leading figures in both psychoanalysis and
at best to optimal marginalisation,1 at worst a backwater of
neuroscience.4 Psychoanalysts in search for scientific credibility
esoteric nostalgia? The focus of psychodynamic psychiatry is a
can now visualise physical correlates of their black-box postulates,
developmental and interpersonal perspective on the origins and
whereas neuroscientists learn from psychoanalysis how meanings
maintenance of psychological illness, together with specialist
can emerge from brain biology. There are numerous areas of
knowledge of psychoanalytically informed treatments able to
mutual interest, including: the distinction between the declarative
alleviate it. The purpose of this editorial is to review recent
memory system and procedural memories and the ways in which
developments, suggesting a muted revival of psychodynamic
the latter may encode early trauma; parallels between the
psychiatrys contribution, in basic science, outcome studies and
conscious/unconscious dichotomy and the interplay between
clinical practice.
cortical and subcortical structures, especially the amygdala;
mirror neurons as the basis for empathy; the role of the right
Developmental psychopathology brain in processing the sensory aspects of memory and the
and the science of intimacy relevance of this to post-traumatic stress disorder; neuroplasticity
and the ameliorative impact of psychotherapy; functional
A developmental perspective is indispensible for understanding magnetic resonance imaging-revealed changes in response to
psychiatric illness. The standard diathesisstress model views therapeutic intervention. No less a figure than Nobel prize-
disorder as resulting from the exposure of genetically susceptible winning Eric Kandel endorses the need for an approach which
individuals to environmental trauma. A psychodynamic viewpoint reconciles the rigorous empirical framework of molecular biology
combines with recent research to gloss this in two distinct ways. yet incorporates the humanistic concepts of psychoanalysis.5
First, environmental susceptibility can be health-enhancing as well
as illness-promoting. To take a recent finding in dopamine D4
receptor (DRD4) polymorphism: given maternal insensitivity, General evidence for psychodynamic
the 7-repeat allele is a vulnerability factor for externalising psychiatrys efficacy
disorders in toddlers, but with sensitive mothers the 7-repeat
allele confers less deviant behaviour. Significantly, from a An earlier cri de cur about the imminent demise of psycho-
psychodynamic psychiatry perspective, such infants respond dynamic psychiatry called for major research effort to establish
better to enhanced parenting, namely psychotherapeutic its efficacy and relevance.6 More recently, a number of
interventions. Belsky and colleagues suggest that these and meta-analyses of dynamic psychotherapy have appeared in high-
comparable geneenvironment findings are best seen in terms of impact journals, with somewhat contradictory results. Leichsenring
plasticity rather than vulnerability genes,2 which confer & Rabung7 found that long-term psychodynamic psychotherapies
reactivity to environmental context, with potential for negative (LTPPs) produced large within-group effect sizes (average 0.81.2)

439
Holmes

comparable with those achieved by other psychotherapy modalities; effective drug treatments for psychosis became available and it
that gains tended to accumulate even after therapy has finished, was shown that many patients dubbed schizophrenic in the
in contrast to non-psychotherapeutic treatments; and that a USA in fact had borderline personality disorder. Eventually,
doseeffect pattern was present, with longer therapies producing McGlashan, a psychodynamic psychiatrist, published a much-
greater and more sustained improvement. Two key mutative publicised follow-up study of patients with schizophrenia showing
factors are a secure, sensitive and interactive working alliance; that psychoanalytic therapy could lead to deterioration and was
and facilitating experiencing of previously avoided painful contraindicated.14 At this stage, it seemed that psychodynamic
feelings.8 Although expensive, psychodynamic psychiatry is able therapy for psychosis was obsolete. However, the Scandinavian
in some circumstances to pay for itself ,9 thanks to offset costs needs-adapted approach to schizophrenia now provides a model
of other expenses (medication, hospital stays, welfare payments, in which the uniqueness of each patient is recognised, medication
etc). Smit et al,10 by contrast, found the evidence for LTPP limited kept to a minimum, the family dynamics around psychosis
and conflicting, suggesting that positive findings may to an extent charted, and a long-term one-to-one relationship with a key-worker
be an artefact of inadequate controls. More research is needed, seen as vital to improvement.15 The needs-adapted approach is
but on balance the evidence does seem to favour psychodynamic not strictly speaking psychodynamic, but contains psychodynamic
psychiatry. psychiatry ingredients in attempting to help patients understand
the nature and meaning of their symptoms, rather than simply
seeing them merely as manifestations of a biologically based
Effectiveness in specific disorders disease.

Two other challenges to the claims for LTPP efficacy are that
patients studied are diagnostically heterogeneous, and it is Psychodynamic psychiatry
therefore difficult to determine the specific indications for psycho- as an integrative discipline
dynamic therapies, and the paucity of head-to-head studies
comparing psychodynamic treatment with briefer, possibly Psychodynamic psychiatrys integrative viewpoint distinguishes it
cheaper therapies. Responding to the second point is a research from its parent discipline of psychoanalysis in a number of ways.
challenge for the future. For the first, the role of psychodynamic First, although effective psychiatric work needs space and time for
psychiatry in a number of specific disorders is beginning to self-scrutiny, today only a minority of psychiatrists undertake
emerge. Anxiety disorders are typically the preserve of personal analysis. Staff sensitivity or Balint groups, mindfulness
cognitivebehavioural therapy (CBT), so it is noteworthy that training and personal coaching are alternative routes to the
Busch and colleagues have developed an evidence-based psycho- capacity for self-reflection needed if countertransferential
dynamic therapy for anxiety, concentrating particularly on the iatrogenesis is to be avoided. Second, rather than espousing
role of unconscious unexpressed anger, demonstrating good specific psychoanalytic ideologies Kleinian, Relational, Kohutian,
outcomes in 21 sessions compared with controls.11 Replication etc. psychodynamic psychiatry fosters treatments which are
is clearly needed. Similarly, there is now a number of tailored to particular disorders, drawing on the best and most
tailored short-term therapies for depression, for which a recent effective psychoanalytic approaches. Third, the psychodynamic
meta-analysis found within-group effect sizes of 0.69, and pre-/ psychiatrist will be conversant in and respectful of other
post-therapy 1.34, both maintained at 1-year follow-up.12 psychological therapies CBT, interpersonal therapy, family
Compared with CBT there was a small (0.30) immediate therapy understanding their indications and different roles.
advantage to CBT but no differences at 3 months and 1-year Fourth, the psychodynamic psychiatrist needs to be skilled both
follow-up. in prescribing medication and delivering psychotherapy, ever alert
The complexity posed by people with borderline personality to the ways in which managing medication may enact a
disorder represents a major problem for psychiatric services. Two transference relationship rather than a medical need. The role of
manualised modified psychodynamic therapies, mentalisation- the psychodynamic psychiatrist, conversant with psychodynamic
based therapy13 and transference-focused therapy have psychiatrys increasingly scientific basis, is to develop advanced
demonstrated significant improvements for patients with expertise in these areas, thereby strengthening the increasingly
borderline personality disorder compared with treatment-as-usual challenged culture of local mental health services.
controls. Mentalisation-based therapy sees individuals with
borderline personality disorder as having difficulties with Jeremy Holmes, MD, FRCPsych, School of Psychology, Washington-Singer Building,
Perry Road, Exeter EX4 4QG, UK. Email: j.a.holmes@btinternet.com
mentalising, that is reading ones own and others thoughts
and feelings, which leads to recurrent interpersonal conflict. The First received 19 Feb 2012, final revision 19 Feb 2012, accepted 23 Feb 2012

therapy encourages reflection on everyday affective crises,


including those with the therapist, rather than offering deep
interpretations. Without the capacity to mentalise the latter are
often incomprehensible or may precipitate feelings of shame and
humiliation. Mentalisation-based therapy is typically delivered References
by specially trained non-medical mental health workers. However,
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Medical Students
poems
by Rachel Clarke
doctors
You come at me with needles bared
And smiles acquired from library guides.
Your coats dont fit, your badges clank,
Your morning shaves a waste of time.

You ask for blood with baited breath,


And furtive attempts to elide
Your novice status at my bed
That Ive lived too long to buy.

Your gods, the docs that barely deign


To grace this old-folk dumping-ground,
Dismiss our ward as nine-tenths dead
And were so dull, the moribund.

Our dicky hearts, our wobbly turns,


Our chewed-up, doe-eared ends of days,
No wonder you young bloods are urged
To use us for your skills, our veins.

So come on then, dont drop your swabs,


Be tighter with your tourniquets,
And try to tame those quaking hands:
The old, youll find, we dont complain.

But as you poke and prod and stab


These crabby, withered arms to find
The blood you need to tick some box,
I ask one thing, please dont be blind

To me, a man whose blood once roared


On Dunkirks sand, in love, in war,
Who drank, raised hell, devoured life,
Ran marathons, adored his wife.

My soul still burns inside dead skin


Im still your age in leather hide.
Ill let you loose on my old bones
If youll just look me in the eye.

This poem is from The Hippocates Prize 2010: The Winning and Commended Poems, published by The Edge Press.

Chosen by Femi Oyebode. The British Journal of Psychiatry (2012)


200, 441. doi: 10.1192/bjp.bp.111.103010

441
Psychodynamic psychiatry's green shoots
Jeremy Holmes
BJP 2012, 200:439-441.
Access the most recent version at DOI: 10.1192/bjp.bp.112.110742

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